New Delhi: Public spending on healthcare has not crossed 1.28% of India’s gross domestic product (GDP) in the last decade. With disease transition--where more Indians are afflicted by lifestyle diseases than communicable diseases--under way, human resource shortages and a continuing fund crunch affect India’s health goals.

This is the concluding part of a four-part IndiaSpend-Observer Research Foundation series on data, healthcare and public policy. As the Narendra Modi government returns to power, we look at the resource constraints that the new dispensation has to address in India’s healthcare.

Given its continent-like diversity, India is undergoing epidemiological, nutritional and demographic transitions in a staggered fashion, with very large state-level variances, recent research by the Observer Research Foundation shows. New challenges posed by non-communicable diseases, as we said, are posing an additional burden on the healthcare delivery system, which is still geared more towards the communicable, maternal, neonatal and nutritional health conditions. Adapting to the fast-changing disease transition requires significant additional financial resources within the health sector.

Despite the Bharatiya Janata Party’s (BJP) titling the health section of their election manifesto as “Health for All”, and the Indian National Congress (INC) starting their manifesto’s health chapter with the declaration that “Healthcare is a public good”, neither party has come close to the promised spending of 2.5% of GDP in the past decade.

The impact of inadequate funding on the health system manifests itself most visibly in terms of insufficient human resources. Given that two-thirds of the public spending on health in India is from the state and local governments, sub-national players are important stakeholders.

The Niti Aayog, the government’s policy think-tank, developed a Health Index in 2018 to instil a spirit of co-operative and competitive federalism between the Centre and states. Along with outcomes and governance issues that were discussed in previous articles in the series (here, here and here), key inputs and processes was the third sub-domain the index explored. Among other things, this sub-domain explored issues of staff shortages and delays in funds transfer.

The proportion of vacant healthcare provider positions in public health facilities is an important indicator explored under this theme. Vacancies of key health staff are linked with both access to healthcare services as well as their quality, according to the Niti Aayog report.

The vacancy status vis-a-vis the total sanctioned positions for both regular and contractual healthcare providers for key positions in public health facilities including auxiliary nurse/midwives (ANMs) at sub-centres (SCs), staff nurses at primary health centres (PHCs) and community health centres (CHCs), medical officers (MOs) at PHCs, and specialists at district hospitals (DHs) was explored as part of the index.

The five best performers with the least percentage of vacancies of staff nurses--among states and union territories with an assembly--are Puducherry (where INC and others are in power), Uttar Pradesh (BJP and others), Tripura (BJP and others), Odisha (Biju Janata Dal) and Nagaland (BJP and others).

The vacancy of staff nurses in PHCs and CHCs was highest in Jharkhand (75%), followed by Sikkim (62%) Bihar (50%), Rajasthan (47%) and Haryana (43%)--all but one (Rajasthan) currently ruled by the BJP and its allies. National Capital Territory of Delhi (NCT Delhi), currently ruled by the Aam Aadmi Party, was the sixth worst with 41% vacancy.

The gaps at the primary-level healthcare delivery system put pressure on the tertiary hospitals, and often force patients to seek help in the private sector, being compelled to “vote with their feet” against government facilities, this May 2015 paper by Oxfam India said.

Similarly, among the states and UTs with assemblies, the vacancy of medical officers at PHCs was highest in Bihar (64%), followed by Madhya Pradesh (58%), Jharkhand (49%), Chhattisgarh (45%) and Manipur (43%). There were no vacancies in Sikkim, while Tripura had 2% vacancies--both currently ruled by the BJP and its allies. This was followed by Kerala (6%), Tamil Nadu (8%) and Punjab (8%).

Many states showed a very high proportion of vacant specialist positions in district hospitals: Arunachal Pradesh (89%) had the highest, followed by Chhattisgarh (78%), Bihar (61%), Uttarakhand (60%) and Gujarat (56%).

Thirteen states and UTs with an assembly had overall vacancy of specialist positions at over 40%. Of these, seven are currently ruled by the BJP and its allies, four by the INC and its allies, and one each by the AAP and the Telangana Rashtra Samithi.

Healthcare staff shortages at the primary level and for specialty care make the private sector the de facto service provider for a vast majority of the population, with adverse financial implications.

Out-of-pocket (OOP) health expenses drove 55 million Indians--more than the population of South Korea, Spain or Kenya--into poverty in 2011-12, as IndiaSpendreported on July 19, 2018.

Funds unspent in states that need them most

In addition to inadequacy of funds, the inconsistency in the timing of funds released by the Centre to state governments has contributed to inequity in terms of service delivery across the country, analysis from the Observer Research Foundation showed.

On average, there were more unutilised funds at the end of the year in the states that needed them the most. Studies have shown that a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down.

The Niti Health Index analysed the average time taken for transfer of Central National Health Mission (NHM) funds from the state treasury to the implementation agency (department/society) based on all tranches of the financial year 2015-16, and found huge variance between states.

Time taken for funds to reach implementing agencies varied from zero days in Daman & Diu and Lakshadweep to and 287 days in Telangana. Almost all Indian states have reported lengthy delays--more than 100 days in many cases--in transfer of funds from the state treasury to state health societies, thereby adversely affecting timely implementation of various health sector initiatives.

Unlike the governance and information sub-index--which deals with the status of the governance structures and information systems within states--the overall performance of the states was mostly consistent with the domain-specific performance within the “key inputs and processes” theme--which deals with human resources, and the level and quality of healthcare and processes.

However, Odisha and Rajasthan performed better on the “key inputs and processes” sub-domain compared to the overall index, according to the Niti Index Rankings. At the same time, all smaller states showed better performance on health outcomes--such as Goa and Manipur--compared to “key inputs and processes”. This aspect needs further study.

If India is to get to a reasonable level of healthcare for all Indians, all mainstream parties in India must agree on a common minimum programme on health down to the state level, to help stop losing time during transition years such as between schemes such as the Rashtriya Swasthya Bima Yojana--started in 2008 by the then United Progressive Alliance government--and the Pradhan Mantri Jan Arogya Yojana launched in 2018 by the previous National Democratic Alliance government, in which Centre-state coordination is key.

As health remains a state subject, and the National Health Policy 2017 has made a logical case for regulation of healthcare, explicitly supporting “the need for moving in the direction of a rights-based approach”, India needs to take urgent steps to reduce bureaucratic delay in fund disbursement in particular, and to improve Centre-state relations within the multi-party federal democratic setup.

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New Delhi: Public spending on healthcare has not crossed 1.28% of India’s gross domestic product (GDP) in the last decade. With disease transition--where more Indians are afflicted by lifestyle diseases than communicable diseases--under way, human resource shortages and a continuing fund crunch affect India’s health goals.

This is the concluding part of a four-part IndiaSpend-Observer Research Foundation series on data, healthcare and public policy. As the Narendra Modi government returns to power, we look at the resource constraints that the new dispensation has to address in India’s healthcare.

Given its continent-like diversity, India is undergoing epidemiological, nutritional and demographic transitions in a staggered fashion, with very large state-level variances, recent research by the Observer Research Foundation shows. New challenges posed by non-communicable diseases, as we said, are posing an additional burden on the healthcare delivery system, which is still geared more towards the communicable, maternal, neonatal and nutritional health conditions. Adapting to the fast-changing disease transition requires significant additional financial resources within the health sector.

Despite the Bharatiya Janata Party’s (BJP) titling the health section of their election manifesto as “Health for All”, and the Indian National Congress (INC) starting their manifesto’s health chapter with the declaration that “Healthcare is a public good”, neither party has come close to the promised spending of 2.5% of GDP in the past decade.

The impact of inadequate funding on the health system manifests itself most visibly in terms of insufficient human resources. Given that two-thirds of the public spending on health in India is from the state and local governments, sub-national players are important stakeholders.

The Niti Aayog, the government’s policy think-tank, developed a Health Index in 2018 to instil a spirit of co-operative and competitive federalism between the Centre and states. Along with outcomes and governance issues that were discussed in previous articles in the series (here, here and here), key inputs and processes was the third sub-domain the index explored. Among other things, this sub-domain explored issues of staff shortages and delays in funds transfer.

The proportion of vacant healthcare provider positions in public health facilities is an important indicator explored under this theme. Vacancies of key health staff are linked with both access to healthcare services as well as their quality, according to the Niti Aayog report.

The vacancy status vis-a-vis the total sanctioned positions for both regular and contractual healthcare providers for key positions in public health facilities including auxiliary nurse/midwives (ANMs) at sub-centres (SCs), staff nurses at primary health centres (PHCs) and community health centres (CHCs), medical officers (MOs) at PHCs, and specialists at district hospitals (DHs) was explored as part of the index.

The five best performers with the least percentage of vacancies of staff nurses--among states and union territories with an assembly--are Puducherry (where INC and others are in power), Uttar Pradesh (BJP and others), Tripura (BJP and others), Odisha (Biju Janata Dal) and Nagaland (BJP and others).

The vacancy of staff nurses in PHCs and CHCs was highest in Jharkhand (75%), followed by Sikkim (62%) Bihar (50%), Rajasthan (47%) and Haryana (43%)--all but one (Rajasthan) currently ruled by the BJP and its allies. National Capital Territory of Delhi (NCT Delhi), currently ruled by the Aam Aadmi Party, was the sixth worst with 41% vacancy.

The gaps at the primary-level healthcare delivery system put pressure on the tertiary hospitals, and often force patients to seek help in the private sector, being compelled to “vote with their feet” against government facilities, this May 2015 paper by Oxfam India said.

Similarly, among the states and UTs with assemblies, the vacancy of medical officers at PHCs was highest in Bihar (64%), followed by Madhya Pradesh (58%), Jharkhand (49%), Chhattisgarh (45%) and Manipur (43%). There were no vacancies in Sikkim, while Tripura had 2% vacancies--both currently ruled by the BJP and its allies. This was followed by Kerala (6%), Tamil Nadu (8%) and Punjab (8%).

Many states showed a very high proportion of vacant specialist positions in district hospitals: Arunachal Pradesh (89%) had the highest, followed by Chhattisgarh (78%), Bihar (61%), Uttarakhand (60%) and Gujarat (56%).

Thirteen states and UTs with an assembly had overall vacancy of specialist positions at over 40%. Of these, seven are currently ruled by the BJP and its allies, four by the INC and its allies, and one each by the AAP and the Telangana Rashtra Samithi.

Healthcare staff shortages at the primary level and for specialty care make the private sector the de facto service provider for a vast majority of the population, with adverse financial implications.

Out-of-pocket (OOP) health expenses drove 55 million Indians--more than the population of South Korea, Spain or Kenya--into poverty in 2011-12, as IndiaSpendreported on July 19, 2018.

Funds unspent in states that need them most

In addition to inadequacy of funds, the inconsistency in the timing of funds released by the Centre to state governments has contributed to inequity in terms of service delivery across the country, analysis from the Observer Research Foundation showed.

On average, there were more unutilised funds at the end of the year in the states that needed them the most. Studies have shown that a file with a request for release of funds has to cross a minimum of 32 desks while going up the administrative hierarchy, and 25 desks on the way down.

The Niti Health Index analysed the average time taken for transfer of Central National Health Mission (NHM) funds from the state treasury to the implementation agency (department/society) based on all tranches of the financial year 2015-16, and found huge variance between states.

Time taken for funds to reach implementing agencies varied from zero days in Daman & Diu and Lakshadweep to and 287 days in Telangana. Almost all Indian states have reported lengthy delays--more than 100 days in many cases--in transfer of funds from the state treasury to state health societies, thereby adversely affecting timely implementation of various health sector initiatives.

Unlike the governance and information sub-index--which deals with the status of the governance structures and information systems within states--the overall performance of the states was mostly consistent with the domain-specific performance within the “key inputs and processes” theme--which deals with human resources, and the level and quality of healthcare and processes.

However, Odisha and Rajasthan performed better on the “key inputs and processes” sub-domain compared to the overall index, according to the Niti Index Rankings. At the same time, all smaller states showed better performance on health outcomes--such as Goa and Manipur--compared to “key inputs and processes”. This aspect needs further study.

If India is to get to a reasonable level of healthcare for all Indians, all mainstream parties in India must agree on a common minimum programme on health down to the state level, to help stop losing time during transition years such as between schemes such as the Rashtriya Swasthya Bima Yojana--started in 2008 by the then United Progressive Alliance government--and the Pradhan Mantri Jan Arogya Yojana launched in 2018 by the previous National Democratic Alliance government, in which Centre-state coordination is key.

As health remains a state subject, and the National Health Policy 2017 has made a logical case for regulation of healthcare, explicitly supporting “the need for moving in the direction of a rights-based approach”, India needs to take urgent steps to reduce bureaucratic delay in fund disbursement in particular, and to improve Centre-state relations within the multi-party federal democratic setup.